RevPaulPediatr.2015;33(3):255---257
www.rpped.com.br
REVISTA
PAULISTA
DE
PEDIATRIA
EDITORIAL
Obstruction
of
peripherally
inserted
central
catheters
in
newborns:
prevention
is
the
best
intervention
Obstruc
¸ão
de
cateteres
centrais
de
inserc
¸ão
periférica
em
neonatos:
a
prevenc
¸ão
é
a
melhor
intervenc
¸ão
Mavilde
Luz
Gonc
¸alves
Pedreira
∗DisciplineofClinical,SurgicalandIntensiveCare,DepartmentofPediatricNursing,UniversidadeFederaldeSãoPaulo(UNIFESP), SãoPaulo,SP,Brazil
Received18May2015
Peripherallyinsertedcentralcathetershavebecome essen-tial devices for continuous or intermittent administration of intravenous therapy, from intermediate to long-term, especially in the intensive care of newborns.1 Known in
clinical practice as PICCs, the acronym for peripherally inserted central catheters, they are used for infusion of fluids,drugs,parenteralnutritionandbloodproducts, pro-motingimprovedqualityofcareastheyareassociatedwith reductionofpainandstresscausedbytheneedformultiple peripheralvenipunctureprocedures,aswellaswitha pre-sumedlowerrisk ofcomplications associatedwithcentral venouscatheters.1,2
Sincethefirstclinical reportsofPICCuseinthe1970s, technologicalimprovementofrawmaterials,insertion tech-niquesandperformanceintheinfusionvolumemaintenance of small-diametercatheters allowed advancesin thecare ofnewborns,particularlyintheadministrationofdrugsand solutionswithextremepHandosmolarity,orsolutionsthat arevesicantorirritanttotissues.2,3
In spiteof thebenefits,theuseof PICCin newbornsis characterizedasacomplexprocedureandrequirestheuse
DOIoforiginalarticle:
http://dx.doi.org/10.1016/j.rpped.2015.05.003 ∗Correspondingauthor.
E-mail:mpedreira@unifesp.br
of guidelines and monitoring of results, aiming at imple-menting good practices and prevention of complications relatedtocatheterinsertion,maintenanceandremoval.It isnoteworthythat,althoughPICCsareinsertedinto periph-eral veins, daily care in the prevention of complications differs fromthat intended tonewborns witha peripheral intravenouscatheter,asthedimensionsandlocationofthe cathetertipresemblethoseofcentralvenousinsertion.3,4
Inneonates,themaincomplicationsrelatedtotheuseof PICCarecatheter-relatedbloodstreaminfections,aswellas catheterobstruction,migrationanddisplacement.1,3
Simi-lartowhatoccurswithchildren,ameta-analysisofstudies onadultpatientsdemonstratedthat,comparedtocentral catheters,PICCswereassociatedwithhigherriskfor malpo-sitioning,thrombophlebitisandmechanicalmalfunctions.4
When studying 559 newborns whoused 626 PICCs,the main causes of complications identified were presumed sepsis,obstruction, edema or infiltration,catheter break-age, accidental removal, phlebitis, pleural effusion and malpositioning.5 The incidence of complications in
new-bornsvariesmarkedlyamongstudies,fromzeroto34%,with obstructionbeinghighlightedasoneofthemajor mechani-calcomplications.5---8
PICC obstruction may arise from thrombotic or non-thrombotic,partialortotalocclusionofthecatheterlumen, whichlimitsor preventstheadministrationof solutionsor aspirationof bloodthroughthedevice.2Itimpairspatient
256 M.L.G.Pedreira
safetybycausingtherapydelayorinterruption.Theuseof largercaliberPICCsmaybeassociatedwithincreasedrisk ofocclusionandvenousthrombosisdevelopment,whereas the use of smaller-caliber ones can contribute to PICC obstruction or other mechanical malfunctions.1 The
non-thromboticcauses of catheterobstruction are variedand couldresultfromthe presence ofmineral, lipidanddrug precipitates,catheterfolds,suturesthataretootight,and malpositioningofthecatheterduetoitsplacementagainst the vessel wall or being compressed by the collarbone or first rib.9 Studies indicate that most PICC obstructions
arethromboticand resultfromfibrin depositioninside or aroundthe cathetertip,withpossibleevolutiontosevere secondary complications, such as infection and catheter-relatedthrombosis.2,9
In an article publishedin this issue, Balaminutetal.10
studied theefficacy of twolow molecular-weight heparin concentrationsintheclearanceof 76PICCsremoved from newbornsafterbeingusedandstoredforuptosixmonths forinclusioninthestudy.TheassessedPICCswere submit-tedtoatechniquetopromotetheoccurrenceofthrombotic obstruction and then randomized into two groups --- one selectedtoreceive adose of25U/mLofheparin,andthe other,adoseof 50U/mL.The techniqueusedfor catheter clearancewasthenegativepressuremethodwitha three-waycannula, and in each study group a professional was responsibleforimplementingtheproposedtechniqueinall cathetersfromthatgroup.Thefindingsindicatedahigher rateofPICCclearanceinthegroupofcathetersinwhichthe higherconcentrationofheparinwasused.
Theuseofheparin,includingthelow-molecularweight type, has been described in the prevention of PICC thromboticobstruction.11---13Theuseofheparinasan
antico-agulantismostoftenusedintheintermittentmaintenance of catheters and shows controversial results; however, as continuousinfusion, inPICC occlusionprophylaxis in new-borns,astudypublishedintheCochranedatabaseconcluded thattherewasapreventiveeffect,althoughwithoutenough power to determine secondary adverse events, requiring clinicalfollow-upoftheresults.11---14Therefore,despite
con-troversies,the antithrombotic activity of heparin maybe considered inclinical practicefor obstruction prevention; however,thrombolyticactionisnotattributedtothisdrug, asproposedinthestudybyBalaminutetal.Theirfindings were probably influenced by the negative pressure tech-nique and the differences between groups suffering the influence of themode of implementation of the catheter mechanical clearance technique, presupposing that the professionalfrom the higher heparinconcentration group performedtheclearancetechniquemoreeffectively.
ForPICCclearance,mechanicaltechniques with differ-ent variations have been described and routinely used in clinicpractice,demonstratingsomesuccessrates,although theymust be used withstringent criteriadue tothe risk ofthrombusdisplacementinsidethecatheterandintothe neonate’sbloodstream.14---16Todate,regardingthrombolytic
agents,moreadequatelycalledfibrinolyticagents,thereare sixknowndrugs,withalteplasebeingoneofthemostoften studiedfor catheterobstruction reversal, despite adverse reactionsthatrestrictitsuse.9,16,17
Studies have shownthat PICC obstruction is character-izedasapreventableadverseevent,throughtheinstitution
of judicious care and interventions, constantly updated based on the best evidence that support the practice whenhandlingthecatheter.1,3,8Inaddition,carestructure
thatpromotesinterdisciplinaryinterventionsforindividual managementofnewbornswithPICC,basedonthe monitor-ing ofresults obtainedin each clinical settingand onthe institution of continuous improvement measures, arestill the best proceduresto promote catheter removaldue to the end of the treatment andprevent complications that cancompromisethequalityofintravenoustherapy.
Funding
Thisstudydidnotreceivefunding.
Conflicts
of
interest
Theauthordeclaresnoconflictsofinterest.
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